Intraoperative Rerupture and Surgical Clipping of a Small Superiorly Projecting Anterior Communicating Artery Aneurysm: 2-Dimensional Operative Video

Anterior communicating artery (ACoA) aneurysms are prone to rupture even at smaller sizes. The surgical management of ACoA aneurysms is highly dependent on the spatial orientation of the saccular projection, categorized as inferior, superior, anterior, or posterior. Superior projecting aneurysms constitute approximately one-third of all aneurysms involving the ACoA. These aneurysms commonly project within the interhemispheric fissure; however, if the aneurysm is not high-riding, it can often be approached via a transsylvian trajectory. The patient presented after subarachnoid hemorrhage with a 3-mm superiorly projecting ACoA aneurysm. The lesion was approached via a right modified orbitozygomatic craniotomy with a transsylvian trajectory. The aneurysm reruptured after minimal manipulation of the dome. Mitigation of the intraoperative rupture was achieved through temporary clip application to bilateral A1 vessels. Bipolar coagulation and placement of 2 permanent clips facilitated final aneurysm occlusion. Postoperative imaging demonstrated patent bilateral A2 flow and no residual aneurysm filling. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

Evaluation of Ischemia Following Clipping of Anterior Circulation Aneurysms with Respect to Temporary Clipping Using Diffusion-Weighted Magnetic Resonance Imaging: A Prospective Study

Temporary vessel occlusion enables a surgeon dissect aneurysm and clip with a lower risk of intraoperative hemorrhage with the associated risk of ischemia. There are studies on permissible time of occlusion of the parent artery using temporary clip; however, the actual incidence of silent ischemic events in patients with aneurysms treated with microsurgical clipping is not well documented. We are trying to look for the association between temporary clipping and incidence of ischemia through this study. The study concluded the statistically significant association between the maximum time of single clip application and ischemia. Intermittent multiple temporary clippings can prevent ischemia instead of a single clipping of longer duration.

Recurrent Giant Anterior Cerebral Artery (ACA) Aneurysm With Previous Coiling, Attempted Clipping Then Direct ACA-to-ACA Bypass: 2-Dimensional Operative Video

Giant aneurysms are defined as lesions with a widest diameter of 2.5 cm or greater and account for 2% to 5% of all intracranial aneurysms. These lesions are challenging entities for microsurgical management with techniques such as direct aneurysmal neck clipping, aneurysm neck reconstructions, aneurysmotomy, and aneurysmectomy. This patient had a previously coiled, unruptured, superiorly projecting giant anterior communicating artery (ACom) aneurysm, eccentric toward the left, for which surgical intervention was undertaken. A left orbitozygomatic craniotomy was performed, and a temporary clip was applied to the bilateral proximal A1 segments. Aneurysmotomy was then performed with internal debulking of the aneurysmal thrombus. Aneurysmectomy and removal of the coil mass were performed. Next, the aneurysm neck was reconstructed using multiple surgical clips. After anticipated aneurysm neck reconstruction, indocyanine green (ICG) angiography demonstrated a lack of flow in the ipsilateral A2. The ACom was then transected along the aneurysm neck, and an end-to-end anastomosis of the distal A1 and proximal A2 was performed. Repeat ICG angiography demonstrated patency of the A1-A2 anastomosis. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

Surgical Management of a Ruptured Dissecting Anterior Cerebral Artery (A2) Aneurysm Utilizing Contralateral Frontopolar for Reconstruction: 2-Dimensional Operative Video

Dissecting aneurysms can pose an immense surgical challenge, and intervention often involves high risk for rerupture because of the volatile nature of the fibrin thrombus overlying the rupture site. This patient presented following rupture of a dissecting aneurysm along the A2 segment of the anterior cerebral artery (ACA). The patient underwent a right orbitozygomatic craniotomy, and the aneurysm was approached within the interhemispheric fissure. Manipulation of the aneurysm dome resulted in intraoperative rerupture of the aneurysm, which was controlled by the application of a temporary clip on the parent A2 proximally and distally. Aneurysmectomy of the thin diseased vessel wall was performed. The defect was filled by transecting the frontopolar branch of the ACA and sewing the frontopolar branch onto the aneurysmectomy defect. This provided a suitable patch for the ACA defect. Postprocedural indocyanine green angiography demonstrated patency of the A2 and the anastomosed frontopolar branch. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

Factors determining best surgical exposure and safe clip positioning in anterior communicating artery (AComA) aneurysms surgery – particular significance of AComA complex rotation in axial plane

Introduction. The aim of this study was to evaluate whether Anterior Communicating Artery (AComA) complex rotation in axial plane may influence the ease of surgical exploration in this region and safety of clip positioning when left vs right-sided approach is compared. Materials and methods. This is a retrospective study based on analysis of patients operated due to AComA aneurysm, both ruptured and unruptured. AComA complex position in relation to coronal plane was evaluated using 3D-CTA VR reconstructions. Next, comparison between surgical approach from the side where A1-A2 junction (angle) was located anterior and posterior to coronal plane was performed in relation to surgical difficulties and intra- and postoperative complications. Results. Subgroup statistical analysis revealed that there is a strong and statistically significant correlation between AComA complex rotation and surgical difficulties expressed by the need of repeated temporary clip application and brain transgression. When anterior vs posterior angle side approach was compared in relation to surgical difficulties and complications, there was a statistically significant difference with strong correlation (p <0,05) in favour of posterior angle side approach. Interestingly, in 72,7% and 45,5% of patients that were operated from the side where A1-A2 junction was located posterior to coronal plane, the approach was performed form the side of a non-dominant A1 and aneurysm dome projection side, respectively. Conclusions. Despite its limitations, our results suggest that microsurgical clipping strategy of AComA aneurysms should at least include AComA complex rotation in axial plane, besides well acknowledged factors, when deciding from which side these lesions will be approached.

Successful Clipping of a Giant Anterior Inferior Cerebellar Artery Aneurysm with Combined Transpetrosal Approach

Background. The anterior inferior cerebellar artery (AICA) aneurysms are rare lesions whose treatment can be challenging. There are only a few previous reports of surgical treatment for such lesions. Objectives. We present a case of a basilar-AICA aneurysm undergoing surgery with the combined transpetrosal approach. Case Description. A 58-year-old female patient presented clinical signs including headache, diplopia, and right hemiparesis. The radiological imaging showed a basilar-AICA aneurysm measuring 25 × 19 mm. The patient was operated via left combined transpetrosal approach. The outcome was graded mRankin 1. Follow-up computerized tomographic angiography showed no aneurysmal residual and total preservation of basilar artery. Discussions. Surgical indication’s purposes were aneurysmal elimination and reduction of mass effect. Combined transpetrosal approach: proximal segment control and enough space for clipping manipulation. Clipping techniques: Temporary clip for aneurysmal collapsing, “orienting clip”. Conclusion. Giant basilar-AICA aneurysm is very rare lesion. Combined transpetrosal approach is appropriate for surgical clipping. Good surgical outcome is achieved with complete elimination of aneurysm.

Individualization of microsurgical tactics during clipping cerebral arterial aneurysms

Objective — to determinate clinical and anatomical options of influence of strategy and tactics of microsurgical treatment cerebral arterial aneurysms (AA) to increase the effectiveness of clipping surgery. Materials and methods. A retrospective analysis of the results of a comprehensive clinical and instrumental examination of 437 adult patients who were operated by clipping cerebral AA, which were on screening and treatment in the department of «Institute of Neurosurgery named after acad. A.P. Romodanov NAMS of Ukraine» in the period from 2009 to 2018 (results of treat of AA distal part anterior cerebral artery (ACA) were analyzed for the period from 1998 to 2015). Men were 235 (53.8 %), women — 202 (46.2 %). In all age groups men dominated. All patients performed a comprehensive clinical and instrumental study in accordance with the supplement to the Order of the Ministry of Health of Ukraine No. 317 dated 13.06.2008. The code for ICD-10: І60.1. Survey results for unification were evaluated according to international scales and classifications. Results. Often, AA was affected by the complex anterior communicating artery (145 (33.2 %)), bifurcation of the M1–M2-segment of the middle cerebral artery (112 (25.6 %)), C5–C6-segments of the internal carotid artery (98 (22.4%)), A2–A5-segments of ACA (79 (18.1 %)). AA of the basilar bifurcation were only 3 (0.7 %) cases. Clinically, cerebral AA was found after ruptured in 382 (87.6 %). Most of AAs were «berry»-type of shape — 364 (83.3 %). Complex AA was detected in 73 (16.7 %) patients. Extended basal craniotomy was used in 46 (10.5 %) cases, pterional craniotomy — in 323 (73.9 %), and other accesses — in 68 (15.6 %). The technique of simple clinging of aneurysms was used in 273 (57.4 %) cases, multiple clipping with clip reconstruction — in 148 (39.0 %), other methods — in 16 (3.6 %). Temporary clip proximally before final dissection was performed in 319 (73.0 %) patients, «pilot» clipping — 76 (17.4%), without proximal control — 42 (9.6 %). Conclusions. When choosing the appropriate strategy and tactics of the microsurgical devascularization of cerebral AA should take into account clinical manifestations and features of the course of the disease. The choice of the optimal microsurgical corridor and AA clinging technique depends on the anatomic-topographic and hemodynamic parameters of AA and the affected arterial segment cerebral artery.

Efficacy and Outcomes of Posterior Inferior Cerebellar Artery (PICA) Bypass for Proximal PICA and Vertebral Artery-PICA Aneurysms: A Case Series

BACKGROUND Nonsaccular vertebral artery (VA) and posterior inferior cerebellar artery (PICA) aneurysms have high morbidity and mortality rates and are difficult to treat using standard microsurgical or endovascular techniques. Definitive revascularization can require clip trapping and/or vessel sacrifice, with PICA bypass. The published surgical experience with these approaches is limited. We herein review our recent surgical experience with PICA revascularization for complex PICA and VA/PICA aneurysms. OBJECTIVE To determine the efficacy and outcomes of PICA bypass for revascularization of nonsaccular PICA and VA/PICA aneurysms. METHODS Retrospective analysis of an institutional review board-approved, prospective database was performed to identify patients with PICA and VA/PICA aneurysms treated with PICA bypass at a single institution. Demographic information, aneurysm characteristics, temporary clip time, and neurological outcomes were recorded. RESULTS Ten cases of PICA revascularization were performed for both ruptured (n = 8) and unruptured (n = 2) nonsaccular proximal PICA or VA/PICA aneurysms. Seven cases were performed without vessel grafts; 3 cases required harvest of the descending branch of the lateral femoral circumflex artery. Mean temporary clip time was 38 min (range 27-50 min). Good outcomes (Glasgow Outcomes Scale score of 5) were achieved in 70% (n = 7) of patients at time of discharge; the remaining patients had a Glasgow Outcomes Scale of 3. Two bypass-related complications occurred in this series; a hematoma at the graft harvest site requiring evacuation, and severe bypass graft spasm requiring multiple endovascular treatments. CONCLUSION PICA bypass can be a safe, effective, and highly customizable tool for the revascularization of patients with nonsaccular proximal PICA and VA/PICA aneurysms.